The
popular image of ME/CFS over the past several decades has generally tended
to view the condition as being that of a new illness - one that has arisen
in the 20th century. This image has been reinforced by the media and some
of the popular (and professional) literature on the condition, with headlines
and titles such as "ME - The New Plague."

So
is the illness that new? Despite this popular belief, it would seem that
conditions similar to ME/CFS have been around for considerably longer
than is generally assumed. The mixture of a broad array of neurological
and muscular symptoms that can occur after an infective illness can be
traced back into history. For instance, as far back as 1750, Sir Richard
Manningham reported a syndrome referred to as 'febricula' (or 'little
fever') that had a large number of symptoms but was hard to objectively
diagnose.[1]
In addition, there have been suggestions in recent well-regarded medical
journals such as the Lancet and British Medical Journal,
that historical figures such as Florence Nightingale,[2]and Charles Darwin[3] may have suffered from a similar
illness. In the case of Florence Nightingale, her illness began after
she returned from the Crimean War and spent years housebound, too fatigued
to talk to more than one visitor at a time (Wessely et al. 1999; Shepherd,
1999; Macintyre, 1998).

In
the mid-nineteenth century the term 'neurasthenia' was popularised by
an American psychiatrist, George Beard, in 1869 for an illness that had
many similarities to ME/CFS. The condition was thought to be "a
disease of the nervous system...characterized by enfeeblement of the nervous
force..."[4] Young women
appear to have been particularly susceptible to it and its onset was frequently
'triggered' by an infection. Other quotes describe neurasthenia as a "...condition
of nervous exhaustion, characterised by undue fatigue on [the] slightest
exertion, both physical and mental...the chief symptoms are headache,
gastrointestinal disturbances, and subjective sensations of all kinds."[5]
Although the term was used very broadly, chronic fatigue was seen as the
"primary or essential symptom" with "its cardinal
characteristics being an inordinate sense of physical or mental fatigue."[6] Thus one can see that there
are many similarities with modern day ME/CFS and neurasthenia (Wessely
et al., 1999).

So if it isn't a new
disease, why has it only recently been increasingly recognised?

The
term 'neurasthenia' began to be used to encompass a range of non-specific
symptoms and consequently the usage of the term began to wane. Interestingly,
In a similar manner to recent medical debate, the medical profession became
deeply divided and polarised on the issue, with there being those who
strongly felt it was a physical illness and others who disputed its validity.
The consequence of this, as Wessley et al. (1999) argue, was that the
failure of the Victorians to provide satisfactory answers to this dispute,
made it inevitable in the 1980's that "both doctors and patients
would experience an almost identical sequence of claim and counter claim
over the legitimacy or otherwise" of ME and CFS.[7]
Consequently, the medical profession has only recently started to increasingly
accept the condition. For instance, the illness in the UK was not recognised
officially by the Chief Medical Officer until 1998, and only after years
of controversial debate within the medical profession.

After
the fall in popularity of neurasthenia, two episodes of ME/CFS in subsequent
decades attracted particular attention, both involving doctors and nursing
staff.

The Los Angeles Outbreak
(1934)

The first of these, which occurred
at the Los Angeles County General Hospital in 1934, was the first ever
recorded outbreak of the condition. Initial thoughts at the time believed
the illness might be linked to polio, but, as the patients' muscles, albeit
weakened, did not waste, this was subsequently not deemed to be an accurate
explanation of events. Around 200 members of staff contracted the condition
and over 50% of them were still unable to work six months later. Their
symptoms essentially composed of:

·Long-duration
muscle pain, tenderness, weakness, as well as sensory symptoms

·Memory
lapses, difficulty concentrating, sleep disturbance, emotional instability,
and being unable to walk even small distances without suffering from fatigue
(Macintyre, 1998).

The Royal Free Outbreak
(1955)

This
is perhaps the best-known incidence of ME/CFS on a large scale in the
UK. The incident occurred over a four-and-a-half month period during the
late spring of 1955. After admitting a number of people with unusual
symptoms, events at the hospital then subsequently dramatically unfolded
when in July of that year almost 300 members of staff were taken ill (of
which 255 had to be hospitalised). As a result the hospital was forced
to close until the early part of October.[8]

The
most curious element was that only 12 of the 292 people ill were patients
already in the hospital during the course of the epidemic. The initial
symptoms developed from a 'flu-like malaise' and became more pronounced
after a short period of remission, when a new set of symptoms arose. The
most pronounced clinical feature of the condition was extreme muscle fatigue
after very minimal exertion; and other symptoms included problems with
brain function (especially short-term memory and concentration) headaches,
blurred vision, and unusual skin sensations. Medical examination afterwards
indicated that the central nervous system had been affected in 74% of
the patients (Parish, 1978; Shepherd, 1999; Macintyre, 1998).

Other Outbreaks

Although
the two incidents at in Los Angeles and the Royal Free Hospital are the
most well known and publicised, there have also been over 70 smaller outbreaks
around the world (Shepherd, 1999).

U.K.

In
the UK a number of outbreaks, albeit of a smaller nature, occurred around
the country such as at Middlesex Hospital in 1952, Newcastle in 1959,
and at London's Great Ormond Street Hospital in 1970-1 (where almost 150
cases occurred).

The UK has also been the source of
much good work, much of which has stemmed from work undertaken by Professor
Behan in the last two decades as well as Dr. Ramsay (who was the first
doctor to acknowledge ME/CFS in the country). As a result of this, the
UK along with the USA is at the forefront of research into the condition.
For a good account of research being undertaken consult Wessely et al.
"Chronic Fatigue and its Syndromes" (1999) as well as Dr. Shepherd's
(1999) aforementioned book.

ICELAND

Iceland
experienced an outbreak in 1948-9 of ME/CFS in a small town in the north
of the island called Akureyri. The incident affected in excess of 1000
people. What proved to be particularly interesting about the condition
was that in a subsequent polio epidemic on the island in 1955, the same
town was apparently unaffected. As a result, it has been argued that the
virus that 'triggered' the ME/CFS outbreak resulted in a level of immunity
to polio (Macintyre, 1998). The origins of the outbreak led it to be called
'Iceland Disease' (Wessely et al., 1999). Information suggests that the
condition is generally well-accepted and supported in the country (Shepherd,
1999).

NETHERLANDS

The
Netherlands appears to have done much in advancing the cause of ME/CFS,
with apparently 70% of the medical profession acknowledging ME/CFS as
a valid condition, and a substantial amount of research work being carried
out (Shepherd, 1999).

ITALY

In
Italy, there is also much good research work being done into the condition.

NORWAY
& SWEDEN

There appears to be a growing acceptance
of the condition in Norway, although many still find it hard to obtain
a diagnosis and get good information on how to manage the condition. In
Sweden there is a small amount of research taking place.

DENMARK

Despite much hostility, there appears
to be evidence that the condition is slowly being acknowledged. However,
despite these improvements, the quality of support and research provision
still lags behind the UK and USA (Shepherd, 1999).

REMAINDER
OF EUROPE

Unfortunately, aside from some minor
research being carried out in Belgium, there appears to little research
being done in the rest of Europe. Some countries such as France, Spain
and Portugal seem to be particularly lacking in terms of medical and self-help
support groups (Shepherd, 1999).

U.S.A

In the USA, despite the occurrence
of additional smaller outbreaks, it was not until a further incident unfolded
at Lake Tahoe in Nevada during 1985 that the US public and media really
took notice. Events took place towards the end of 1984 when a number of
previously healthy adults came down with an unusual 'flu-like' illness
followed by symptoms linked with ME/CFS such as muscular fatigue and cognitive
problems. Blood tests taken from those affected failed to reveal anything
unusual, and this led a number of doctors to become sceptical as to whether
the patients were actually physically ill.

Around the same time and stimulated
further by the Lake Tahoe event, researchers began to look into the possible
relationship between the virus linked with glandular fever, the Epstein-Barr
virus (EBV). Medical researchers such as Drs. Cheney and Peterson began
to speculate as to whether the symptoms of sore throats, raised glands
and headaches that those at the Lake experienced could be caused by glandular
fever (infectious mononucleosis). Papers around the same time, from Israeli
and American researchers, appeared in high-profile medical journals such
as the 'Lancet' (Tobi et al., 1982) and 'Annals of Internal Medicine'
(Jones et al., 1985; Straus et al., 1985) pursuing this line of enquiry.
Many researchers wondered whether, as the Epstein-Barr virus belongs to
the herpes family of viruses which can stay dormant in the body, the symptoms
could be due to a reactivation of the virus (Wessely et al., 1999).

However, the findings showed that
although around three-quarters of the patients had raised antibodies to
EBV, the remainder had normal or even no EBV antibodies. Their theory
also became problematic due to the fact that EBV antibody tests are particularly
difficult to interpret and that the spectrum of test results from the
patients were similar to what would be anticipated from normal healthy
adults from a common background. Furthermore, most people by the age of
30 have been exposed to the virus, with only a few going on to develop
glandular fever (Wessely et al. 1999; Shepherd, 1999).

'Chronic
Epstein-Barr Disease'

Despite
these questions, the US media quickly picked up on it, with publications
such as Newsweek calling it 'the malaise of the 80's', while others referred
to it as 'yuppie flu' as a great number of those taken ill were young,
active professionals. Although there was still uncertainty over the implication
of the glandular fever virus, the term 'Chronic Epstein-Barr Disease'
or 'Chronic Mononucleosis' caught the public's imagination, and became
the commonly used term for the condition. Subsequently, further attention
became focused on a recently discovered virus in the same family, Human
Herpes Virus Type 6 (HHV-6) (Wessely et al. 1999; Shepherd, 1999).

CANADA

In
Canada, there does not appear to have been any major clusters of the illness
and as a consequence the condition has received less attention and awareness.
Nevertheless, efforts from the support group, ME Canada, has helped increase
recognition of the illness in the country.

AUSTRALIA

One
of the earliest incidences of ME/CFS in Australia occurred in Adelaide
in 1949, when 700 people were admitted to hospital with a ME/CFS like
illness. Australia has also been a great source of research into the condition,
especially into aspects of immunology, infection and management. This
led, for instance, to the creation of a Working Group by the Royal Australian
College of Physicians in 1998, which gave instructions on how to best
diagnose and manage people with ME/CFS (Shepherd, 1999).

NEW
ZEALAND

In
New Zealand, an outbreak of ME/CFS in the South Island region of Otago
in 1984, led to the illness being dubbed 'Tapanui Flu'.
Those affected by the condition
initially developed a 'flu-like malaise' and suffered from debilitating
fatigue for several weeks afterwards. A subsequent 10-year study on 21
of those affected, in the journal, Archives of Internal Medicine,
showed that 16 of the 21 had been able to achieve an almost full-degree
of functioning by the end of the ten year period (Levine, 1997).

Past research in New Zealand has tended
to focus on retroviruses, immunological aspects, and on haematology (looking
into potential abnormalities in red blood cells). There also seems to
be an increasing acceptance of ME/CFS in the country and support group
provision is good (Shepherd, 1999).

SOUTH
AFRICA

Curiously,
in South Africa, a similar incident to the Royal Free Hospital outbreak
in the UK, occurred in Durban many thousands of miles away a few months
earlier. In common with most outbreaks, there were possible connections
with polio.

Unfortunately, the condition is still
only very gradually starting to be accepted by doctors and there appears
to be a lack of good quality information on the subject (Shepherd, 1999).

JAPAN

Research
in Japan has tended to focus on immunological abnormalities linked with
the condition; on muscle abnormalities, especially carnitine deficiency;
and the influence of certain potential viruses. So far Japanese research
into the possibility of carnitine deficiency and its impact upon muscle
fatigue (Kuratsune, 1994) has been supported by subsequent work in the
UK (Majeed, 1995).

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